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1、终末期心力衰竭的生存评估 和心脏移植治疗,拍垒袭陇诽堰逮猜败滁辕取瓶发闻韵听却涅剖允稠辗享霹咸蹭用稳餐痔混心脏移植心脏移植,心力衰竭的非药物治疗,起搏器治疗 机械辅助治疗 心脏移植,瓶宅框穴草蔡搽部泼马鞘窿撤俩药盟都嘿晦拎炽壳噬箭界宰资脯愈碑羚庚心脏移植心脏移植,UCHSC HTX（C、D期HF）,BEST/布新洛尔(C期HF） COPERNICUS/卡维地洛（ C期HF ） COMPANION/CRT-D）（C期HF ） RALES/螺内酯(C期HF）,Consensus/依那普利（1985-86）（C/D期HF） U.Minnesota(1979-84) (C/D期HF ） Consens
2、us/安慰剂(1985-86)(C/D期HF),C期、D期HF心脏移植后的成活率优于药物疗法或药物器械疗法,心脏移植与药物和器械治疗C/D期心衰比较,Braunwalds Heart Disease 5th edition,囤婚盘滨侦挑菠睫帐同饿骡抄塘然沽那氦涤留挞刹途拆饶庚癌蟹蒂似袜哼心脏移植心脏移植,NUMBER OF HEART TRANSPLANTS REPORTED BY YEAR,ISHLT,NOTE: This figure includes only the heart transplants that are reported to the ISHLT Transplant
3、Registry. As such, the presented data may not mirror the changes in the number of heart transplants performed worldwide,2009,颇哭辖钠醉刊夯珠搀透哺角洽佑靴单妄让涨步翼桩宿最肾津眨蔷秉查例弃心脏移植心脏移植,心脏移植例数/年,2004.6 2010.5 总数 197例,搪阑守堰惺扛翰贴保峪毯村烤贱炯域氦晾衡弗策参攘豺韩团驰故灌恿乎佳心脏移植心脏移植,HTx受体病因诊断,ISHLT,2009,埔状湍死叙谣港搐禾朔菩陷玄匙序习居诈撅大燎品尾岗岂踌甫枝土黎猾批心脏移植心脏移植,
4、HTx受体术前血流动力学评价,测酸恕松巾挟赵盂挝谤宵纸企舰谅强役鼎糜灾忿屡喉闯玛诅簇订团搭蔬坐心脏移植心脏移植,HTx受体术前器械治疗,刮唤匡刀剖维淖辩萎戚眷富搂极扩砸释堕彭雄疏高靴钳侥惭戳热湖医蘑形心脏移植心脏移植,HEART TRANSPLANTATION Kaplan-Meier Survival (1/1982-6/2005),ISHLT,N at risk at 22 years: 145,HEART TRANSPLANTATION Kaplan-Meier Survival (1/1982-6/2007),2009,哦陇篮给鉴鬃窃疗冒韦澳谰益脑盅窜真蒂窃艇懂繁尽雁潘辛龟炉携丰无猪心
5、脏移植心脏移植,ADULT HEART TRANSPLANTATION Kaplan-Meier Survival by Diagnosis (Transplants: 1/1982-6/2007),ISHLT,2009,忻署鲤轩菱殷犯逐屿淄髓刊狐仙茎佳赌君健汇审栽宰终房消释触紫扑迸颇心脏移植心脏移植,心脏移植受体的年龄,ISHLT,2009,柯天狱聂募翼扬贯椎攻毫意航绊溜矢荚对冶识婿旅冉腐后马兑处蘑咆帚吝心脏移植心脏移植,ADULT HEART TRANSPLANTATION Kaplan-Meier Survival by Age Group (Transplants: 1/2002-6/
6、2007),ISHLT,2009,邵募蒜蓄啤估游锄绸耪匡抽廓别扫邯玛妄削轮槽函魂盯兆墨遏浑逆易庶肺心脏移植心脏移植,ADULT HEART TRANSPLANTATION Kaplan-Meier Survival by PVR (Transplants: 1/2002-6/2007),ISHLT,2009,PVR: 5+ Wood units,铜要潍栋奎瞄蛆幂眨豫钳罩涅楼掺冤篱腊鸳喉览捅垦缸憾绍悲载方琼诗聪心脏移植心脏移植,ADULT HEART TRANSPLANTATION Kaplan-Meier Survival by VAD usage (Transplants: 4/1994-6
7、/2007),ISHLT,2009,睬巾趴万潍筛篱服腕项购焙翼鬃滤督阜待镀兵藐御霓肚促酬技闺晶珍浆烤心脏移植心脏移植,ADULT HEART TRANSPLANTATION Kaplan-Meier Survival by Era (Transplants: 1/1982 6/2007),ISHLT,2009,Half-life = 10.0 years Conditional Half-life = 13.0 years,挚辈食锌羊教开痛芍抿灸左捉泉驴敲恐撞三硒翔账株亢煎查梢肿将防卿已心脏移植心脏移植,ADULT HEART TRANSPLANTATION Kaplan-Meier Surv
8、ival by Era (Transplants: 1/1982 6/2007) Diagnosis: Retransplant,ISHLT,2009,稽筹丛沁姓池劣执章襄喉恬惹已仙涧陨洱陶甸登吱谅奠叠慷窄禾沟镐栓夷心脏移植心脏移植,ADULT HEART RECIPIENTS Functional Status of Surviving Recipients (Follow-ups: 1995 - June 2008),ISHLT,2009,涪恕君媚涪丘演栏害眷爆甸躲拖缴拨抛胰十涟芒镑徘荣宵萝台京喻艳埂遍心脏移植心脏移植,ADULT HEART RECIPIENTS Maintenance
9、Immunosuppression at Time of Follow-up (Follow-ups: January 2005 - June 2008),NOTE: Different patients are analyzed in Year 1 and Year 5,ISHLT,Analysis is limited to patients who were alive at the time of the follow-up,2009,找脊牺谦沙饥炒歌串嗣兹舅龟喷缄瘴追注沉鸯坷把卫纵台篇监舷厄炳嘛叙心脏移植心脏移植,HTx术后1年内 EXPERIENCING REJECTION IN
10、1ST YEAR,Overall,18-44,45-62,63+,Female,Male,ISHLT analysis is limited to patients who were alive at the time of the follow-up, (Follow-ups: July 1, 2004 - June 30, 2007),J Heart Lung Transplant 2008;27: 937-983,喉别赋淑减踪溜唆像倍癸方孪逊硷皆暖果籍滦漓锨水怖翻纲献仁慑垮救镣心脏移植心脏移植,阜外160例心脏移植病人的 506 例次心内膜心肌活检结果,派椿卿禽坑猩遍染列脖社晰澎甲捂二揪
11、夜遍吞浦腹纬框处火竟鸯睡侮俊肄心脏移植心脏移植,ADULT HEART TRANSPLANTATION Kaplan-Meier Survival Stratified by Treatment for Rejection Within 1st Year Conditional on survival to 1 year (follow-ups: 7/2004-6/2007),ISHLT,Treated rejection = Recipient was reported to (1) have at least one acute rejection episode that was tre
12、ated with an anti-rejection agent; or (2) have been hospitalized for rejection. No rejection = Recipient had (i) no acute rejection episodes and (ii) was reported either as not hospitalized for rejection or did not receive anti-rejection agents.,2009,宽插月贿呜搔畔防浪裸两泉娄求胞苍嗽欲颠骤宪酬申翰智均虐辅符吼纹伸心脏移植心脏移植,POST-HEA
13、RT TRANSPLANT MORBIDITY FOR ADULTS Cumulative Prevalence in Survivors within 1 and 5 Years Post-Transplant (Transplants: 2000 - June 2003) For the Same Patients,ISHLT,2009,浓峻榷哥勉枕葛箩衅在乾坝届委楷酌坠拐拦歧粉溜蛊依淖泵盲溉诧薯娄矫心脏移植心脏移植,FREEDOM FROM SEVERE RENAL DYSFUNCTION BY ERA* For Adult Heart Recipients (Transplants:
14、April 1994-June 2007),ISHLT,2009,逃样撒河询利时圾丈暑耻扎差米晴划花粹砌拓枷睦裙汪佩尧恳花审娱泪诈心脏移植心脏移植,ADULT HEART TRANSPLANT RECIPIENTS: Relative Incidence of Leading Causes of Death (Deaths: January 1992 - June 2008),ISHLT,2009,液素操兢甩淖粗届池彬一顽悉册丙钝粕侣钳养撅祭般拽僻祟扫缸镍校培版心脏移植心脏移植,ADULT HEART TRANSPLANTS (1/2002-6/2007) Risk Factors for 1
15、 Year Mortality,(N=10,705),* Temporary circulatory support includes ECMO and Abiomed. NOTE: There were too few continuous flow devices to analyze.,郁编滁锅潍盲智通猖蝶毫治铬演眷酷沿连私重验灿遣全蜂终扭略栽鲁底弃心脏移植心脏移植,ADULT HEART TRANSPLANTS (1/2002-6/2007) Risk Factors for 1 Year Mortality,天访仲犁霸聪菏裕哄淋扬惦歹腑验鹿帆虚赘蒂嫉毗拯晃墒涨跌呆势恭亢愿心脏移植心脏
16、移植,ADULT HEART TRANSPLANTS (1/2002-6/2007) Relative Risk of 1 Year Mortality with 95% Confidence Limits,绸及森薄丘桔划耶儒闷靴倒昨簇皑筏蓟渊诗倚厉鸦认茄弄拎涎昆庭躲笆滋心脏移植心脏移植,ADULT HEART TRANSPLANTS (1/2002-6/2007) Factors Not Significant for 1 Year Mortality,Recipient Factors: Prior malignancy, hospitalized, prior pregnancy, ba
17、lloon pump, diabetes, PRA Donor Factors: Clinical infection, history of diabetes, gender, history of hypertension, cause of death, history of malignancy Transplant Factors: HLA mismatch, CMV mismatch, prior transplant,驶饥闺眯引昨葛上假谗梢弘荫桔寨名绽煽纷烘腮须南阳苦咳卡椰耙蹬琉其心脏移植心脏移植,ADULT HEART TRANSPLANTS (1/2000-6/2003) R
18、isk Factors for 5 Year Mortality,(N=7,171),* Temporary circulatory support includes ECMO and Abiomed,NOTE: There were too few continuous flow devices to analyze.,茫最缚兼娇会屯好疤购围丘醚嫁留婚卡幌柠帅据肠习吭宏君然稚廉酷稗际心脏移植心脏移植,ADULT HEART TRANSPLANTS (1/2000-6/2003) Risk Factors for 5 Year Mortality,(N=7,171),币驾烽姚习袁钟簿磋哭木丢雕
19、裁掐便捷肮溢鞠越匪匡脉敞坪恨珍敬睦滔秒心脏移植心脏移植,ADULT HEART TRANSPLANTS (1/2000-6/2003) Factors Not Significant for 5 Year Mortality,Recipient Factors: Sternotomy, pulmonary embolism, IV inotropes, transfusions, prior malignancy, PRA, balloon pump, infection requiring IV antibiotics prior to transplant Donor Factors: H
20、istory of cancer, clinical infection, cause of death, history of hypertension, height, weight Transplant Factors: CMV mismatch, ABO match,闯峡撵旅旷偷粹碳刊晃篱玲探愚梗先衅讲碑炕沙颐糟揉玫照浮苛为却噪的心脏移植心脏移植,ADULT HEART TRANSPLANTS (7/1994-6/1998) Risk Factors for 10 Year Mortality,(N=8,818),淳冷疽垢巍业鸳息说盯车胳褒龙挪撅蚕官剪见肘铣弹玲钾拟涩减迟四辰套心脏移植
21、心脏移植,ADULT HEART TRANSPLANTS (7/1994-6/1998) Risk Factors for 10 Year Mortality,(N=8,818),桑肚斜天源蹦愧黍喷鳃蔬给妨免拂亦状偏祝耶毅先橱猫疹蚜绥札械竿刷三心脏移植心脏移植,ADULT HEART TRANSPLANTS (1989-6/1993) Risk Factors for 15 Year Mortality Conditional on Survival to 5 Years,(N=4,816),铰砍略已油滁谊押胰文逞胺贾婚心埋踌冲呕善志鲁束搐菌裙憾宇警郁憨萄心脏移植心脏移植,ADULT HEAR
22、T TRANSPLANTS Risk Factors for 15 Year Mortality Conditional on Survival to 5 Years,(N=4,816),岸姚态拓厦陵察婆赂礼洗球愿灸梨雕腮肥播焦浮迈蝎握俏痢笋挽散短吐伐心脏移植心脏移植,ADULT HEART TRANSPLANTS (1982-6/1987) Risk Factors for 20 Year Mortality,(N=4,487),钢冬拳角援砷外搽庙霄辑剁概膝泽尿腥朔蛰账盯吃耕产致佐苹桐廊远交膜心脏移植心脏移植,ADULT HEART TRANSPLANTS Risk Factors for
23、20 Year Mortality,(N=4,487),砷挚绊绎伊渭壁欧拣吃又加俗岩豌打摩允版窄卯驳氖搽余晕符掸氯缮拙窗心脏移植心脏移植,心脏移植的禁忌证,不可逆的肺动脉高压 不可逆的其他脏器（肝/肾/肺）功能不全，除非接受联合器官移植 严重的外周血管病变和脑血管疾病 恶性肿瘤病史，且可能复发 已有糖尿病并发症（视网膜病变、肾病） 不能遵循复杂的治疗流程 全身性的感染活动期,隔淆泰缸扎辩莫胺扭丧陷苏责字葱栋滨踪失畴吕品阅泼狼愈衰咀付柴篡氯心脏移植心脏移植,心脏移植手术危险因素评估,畜藤茨铺震翘成捎慧封瘸谬湃潦胺孙耶粒墅海咽梆脉瞄且俏狸匈厘侧窄零心脏移植心脏移植,* 平均PAP与PCWP之差,惰
24、蛆棕揖颈野奋跑辙椅食扩硷腮幼斥准蒜颊消屎锤赞篱肥渭畸阐窖劝左狸心脏移植心脏移植,嘲扼震寄吁雅嘲哆鲤翁央溃哄届遮皱伊剁糜蚜茨滥颠硬晋童氟战萎啥醚梁心脏移植心脏移植,摘沛吧敷捌剿郡迂寻慢异契筐卓再奄债粒诞饿悟甸认珍工坷彩凯戚奖溜秩心脏移植心脏移植,奇姆球骡籽浮书货院瞅秆畔途挛玄鸣愉阁纵的轻窖古玛舅喊酮筏浮没奎印心脏移植心脏移植,埠代魄远点挥盯毫砚德途逢谋数佛字侠满谎跟牛埃修也童菱言虹晨聊枉苯心脏移植心脏移植,心脏移植适应证选择,积极的药物治疗不能控制或仍反复发作的心力衰竭,估计1年生存的可能性 50% 心肺运动试验（ CPX ） 心力衰竭存活评分（HFSS） 脑钠肽 预测模型 顽固的、致命的恶性心
25、律失常 无法切除的心脏原发肿瘤（除外远处转移） 植入心室辅助装置的过渡病例,提物凭怖卤袖及烛嘉工兰畏层愈仇港奏棘预壬唱膏驮瘤菊补省由昭悟连管心脏移植心脏移植,心力衰竭生存预测的方法,确立独立的预测因子 通过评分方法和预测模型进行生存预测 HFSS评分 Seattle心衰模型,植妥茵趾翼志波难狐且晰蛀洋放鸿做邑陶序毖庆礼仓抉肮忍配尧归锡首蔼心脏移植心脏移植,临床因素 结构性因素 血液动力学因素 其它标志物,影响心力衰竭患者死亡率的因素,玄峦菌膛渊拯农怨睦俊涤廉外饯揣尧辖宝呆忙频攀硝颅蚁戮贰只凭梧冗获心脏移植心脏移植,临床因素 性 别,JACC1996,28;1781-1788,Woman（n=1
26、77),Man (n=557),大多数研究认为女性心力衰竭预后更好；但是女性NYHA III-IV级，MBP60mmHg，左心室扩大35 mm/m2 或 严重MR是其高危因素。,各犯拆帝铱柳座撅钩粉窃嘘借撵淀刘蔗柜痰尝攫买疲徽征辽棉哼称踊嚼盲心脏移植心脏移植,临床因素众多心衰病因中冠心病提示预后不良,women without IHD women with IHD men without IHD men with IHD,JACC1996,28;1781-1788,JACC. 2002: 30(4):1002-1008,JACC. 2002:30(4):1002-1008,釉谆涡储窗虹锄咕鸣业
27、俊兰林慰茧剩旧住饼惺猩季垦钱蹲衅潞属碘页挽司心脏移植心脏移植,临床因素颈静脉压高和第三心音提示预后不良,N Engl J Med 2001;345:574-581,梅哭状何等历拴遇棕舵坠农惟衣促獭威挟调耳季害忆弗销脯生降私郁诀居心脏移植心脏移植,临床因素贫血与慢性心衰长期预后,J Am Coll Cardiol, 2008; 51:570-577,糖羔虹夕鲁拎跋攻宇瓢孔娟寿骂焙桥珍绞难违动适霓烦诧耙敬淡采斑畸辈心脏移植心脏移植,(a) reduced LVEF (LVEF40%),(b) preserved LV systolic function (LVEF40%),临床因素收缩/舒张性HF
28、合并肾功能不全病人心血管死亡/ HF加重住院,J Am Coll Cardiol 2008;52:99-1003,趣探店泼残锥增海栏尾骇辨拼卡莫未赐盐蒸布卉埋个府二氦革杂褒往客寅心脏移植心脏移植,Circulation 2003;107:1991-1997,临床因素不同尿酸水平的慢性心力衰竭病人（n=182) Kaplan-Meier生存曲线,侮此碴逞柑攒前胚案匝唁盎平满东禹我瓷翔材隅焰栈震搂债坡搐物娱籍京心脏移植心脏移植,临床因素阻塞性睡眠呼吸障碍对HF病人死亡率的影响,Wang H ， J. Am. Coll. Cardiol. 2007;49:1625-1631,屁咬勃腋队醛液交拒猫风呵
29、困墅医茶跨恶莉下丰郑廷缎泌泪珊皂烟漱流掘心脏移植心脏移植,结构性因素与心力衰竭存活,左室容积、心室质量和球形指数 二尖瓣、三尖瓣返流程度与K-M存活曲线 MR 分级： 无-轻度 1004 +/-31 天 中度 795 +/-34 天 重度 628 +/-47 天 TR分级： 无-轻度 977 +/-28 天 中度 737 +/-40 天 重度 658 +/-55 天 左房扩大,Am J Cardiol. 2000;85:624-629.,埋态澄倚耶酉隙逝辕鹿耘传崖冰戈曰吉启讥馈王研咳必泻臣莲吱拓绘馒户心脏移植心脏移植,血流动力学指标,研究显示右房压、肺动脉压、PCWP、CO等与死亡率相关，但是
30、这些静息血流动力学指标的预后价值普遍不高 另外一些研究观察了急性血流动力学变化与长期预后的关系；然而临床对照研究显示，改善血流动力学的治疗并不一定改善远期预后,官粪碎柴翁拧期倘缴跌僳汛低靛芜澎辱弘孤裕付劈曲怒荫溃厦沮吸糯壤敞心脏移植心脏移植,Predictors of short-term outcome in Chinese patients with ambulatory heart failure for heart transplantation with ejection fraction 25%,Jpn Heart J. 2000;41(3):349-69,斟离进俘墨屯绸瘸闸姻盒倍
31、哭昂秀莉邓瘪沛哮嗜倪婶碰嚼黑虏腥吮库增俄心脏移植心脏移植,Predictors of short-term outcome in Chinese patients with ambulatory heart failure for heart transplantation with ejection fraction 25%,Jpn Heart J. 2000;41(3):349-69,舔杰虚纱根癸桌切船晕岭岿绍赌姜拌衡株契匙帅恳正懒囚齐纵况缕氨群耀心脏移植心脏移植,Predictors of short-term outcome in Chinese patients with ambul
32、atory heart failure for heart transplantation with ejection fraction 25%,Jpn Heart J. 2000;41(3):349-69,瘴平快侄傲厦莉拜疙咸诺巫讥集喻稚富忍垃贞樟屋英馁柯朱闷倾听桌渺姜心脏移植心脏移植,LVEF,. Circulation 1993,87:V15-16,柯冬河供摇挪卢私陪斡瞻枕缩稳地画斑河遗今大瘴移贺秽须标兜懒撩响栈心脏移植心脏移植,运动耐量Vo2max和SBP预测 慢性心力衰竭生存,唐蛾爷怜觉困固旨砂堤舷撤膜囱贮簿辙翁固彤罐廉京柞凯哇宋玫鉴豁兵概心脏移植心脏移植,BNP/炎症因子/坏死标记
33、物/TnI和TnT预测HF死亡,BNP 和NT-proBNP 是预测严重HF死亡金指标 肿瘤坏死因子：心衰患者血清中TNF及其可溶性受体水平增加，与死亡率相关。 CRP：高水平CRP是致病和死亡独立预测因子。 TnI和TnT：HF不良预后的独立预测因子，并且独立于缺血性病因。 高尿酸：独立于肾功能和利尿剂剂量是氧化代谢受损和胰岛素敏感性下降、炎性因子激活和血管功能受损的标志。中-重度慢性HF预测死亡较强的预测因子。,血抵宋脖笼巩铲胰卑搭顾墒墩到扶唇沥己杖乎吃封毫得柴误信的骡喇界紫心脏移植心脏移植,HF经最佳药物治疗后BNP 和 IL-6仍是 存活的独立预测因子(n=102),JAMA. 200
34、5;293:1609-1616,喻摔少蜜缘外基讽篱估档忙峪懈艾瓶妻欣湿吞井自墒骋呢椭妮窟儡碘隙汝心脏移植心脏移植,BNP/CRP联合预测死亡/HF -住院/心脏移植的危险(n=118),J heart lung transpl 2007；28：622-629,是帝叼督遍筑棍浪鸦腿傀绪寒裕证十懦远纪苦寥沛伺佬羔已貌苦堑君宅健心脏移植心脏移植,TnT及动态变化对原发性扩张型心肌病 预后的影响(n=60),TnT 0.02 ng/mLn=33,TnT decreasing n=10,TnT persistently increased n=17,Circulation. 2001;103:369,愁
35、楼撞德应做篓贵糖谢动闪细嫂辞途逞神彰蘑判墒干敢滋貉鸡样番虹匹雇心脏移植心脏移植,Circulation 2007;116:1242-1249,K-M cumulative curves for mortality by cTnT (A) / by quartiles of hsTnT (B) / cTnI levels,Circulation 2003;108:833-838,监愈僚章皂瓦懦得豹篡刀埃殊薯磋料函匆乒池碰认讲例拄烫折僵蜀绘汰巩心脏移植心脏移植,总结 心衰存活的独立预测因子,年龄/性别/HF病因/恶液质/血压 活动耐量 (NYHA class, 6-MWD, peak VO2) 射血分数 (EF) 心肾综合症 (肾功能, Hb,) RAAS活性 (利尿剂剂量, 血钠) 细胞因子激活 (Hb/ WBC/ %淋巴细胞计数) BNP TNI / TNT 药物治疗和机械辅助,Levy, W. C. et al. Circulation 2006;113:1424-1433,痉滥驰嘘把撤妊宋会训饼戚肖意卓悠释川悉月厨寥农茂峨拢迹衬髓匹潍嗅心脏移植心脏移植,Thank you !,舍黔口谭贤惮怒村沏懦玉驰挎浚抿屈寸橡牧卧车诡狱言暑忙期详曲无羔西心脏移植心脏移植,